Project Summary. The escalating rates of obesity in nursing homes (NHs) present unique challenges to these facilities. Providing appropriate care to obese residents can be costly as obese residents have special care needs and accommodating these needs requires additional investment in equipment and staff time. However, the current case-mix payment systems do not recognize the additional costs associated with obesity (i.e. the case-mix algorithm is not rated on obesity status), and the resulting potential inverse financial incentives may create barriers for obese residents to receive high quality of care. It is important to understand the potential quality barriers faced by obese NH residents because suboptimal care, if existing, will not only impair obese residents' health conditions, but also incur unnecessary costs, such as potentially preventable hospitalizations, on the Medicare program. To date, there has been very limited empirical evidence bearing on this issue. Our prior study provided some preliminary findings that obese residents received lower quality of care than non- obese residents along one specific dimension - the prevention of pressure ulcers. However, the NH quality is multidimensional and quality measures are not necessarily to be correlated. There are no studies examining whether disparity exists in other NH quality outcomes for obese residents, and whether obese residents face barriers in accessing high quality NHs. Thus, the objective of this study is to understand disparities both in access to care and in quality of care experienced by obese residents. Based on an economic conceptual framework, the study has 2 specific aims: 1) Examine the disparity in quality of care, using multiple measures (fall, preventable hospitalizations etc.), received by obese and non-obese residents within the same facility, and whether such disparity varies with the facility ownership, state Medicaid reimbursement rate and market factors; 2) Understand the disparity in access to high quality NHs ? that is, whether obese residents are less likely to be admitted to high quality NHs than non-obese residents ? and the impact of quality report cards. This study is innovative because it is the first one to use a comprehensive set of quality measures to examine quality of care received by obese NH residents; it employs an economic framework to explore different pathways (i.e. care received within a NH and barriers to access to high quality facilities) that can lead to the overall difference in quality of care between obese and non-obese residents; and it explores how the quality gap varies with ?external factors? such as state Medicaid policies and market factors, which will not only provide policy relevant implications, but also provide further evidence on the role of NH in the quality outcomes experienced by obese residents. This proposed research is significant because it addresses an emerging and growing public concern. Furthermore, it will provide information on the needs of care among obese residents and needs of policy interventions, with the goal of reducing health disparities, achieving better care and reducing health care costs.